Pediatric Admission Profile

Page 1

Timothy W_

Date: 12/20/95

Valuables
Hearing Aid: N/A
Clothing: Sent Home
Other: N/A
Other: N/A
I fully understand that HUMC (REDACTED - because location is wrong OOG) is not responsible for any personal property brought in or retained at the bedside at any time. I fully understand that HUMC provides a safe for my valuables should I wish to place them there for the hospital stay.

Section III: Psychosocial History
Tobacco: No
Has patient or someone in your house smoked in the last year? Yes
If yes, would you like: Patient/Family refused
Alcohol: No
Illicit Drug Use: No
Cultural needs/considerations affecting hospitalization/plan of care: Denies

[There is no Section IV]

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Section V - Growth and Development
Prior to admission able to complete ADL: Yes

Section XII - Initial Discharge Assessment:
Previous Home Care Services: No
Who does child live with? Mother
Who will care for the child at home? Mother
Based on obtained child patient information and nursing assessment - referral related to discharge needs made to: Case Management

Cribs must have rails up at all times when occupied (Not checked)
No toys or objects to create sparks or friction if in croup tent (not checkted)
Bed/crib must be kept in lowest position at all times (Not checked)

Immunizations Current? Yes

Chief Complaint: Headaches, insomnia, (REDACTED)

Disposition of Valuables (REDACTED)
Caldwell County Hospital (REDACTED, but probably for consistency's sake since the location isn't right.) will not assume responsibility for lost or damaged valuables, clothing, or personal items kept in the patient's possession. Valuables should be taken home or secured by the hospital.
Patient/Family Signature:
Witness Signature:
Date: 12/20/95
Time: 12:01 P.M.

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2. Habits: Tobacco
Member of household uses tobacco (Note: It is listed such that Tim himself does not use tobacco at this age, but rather, a member of his family does.)

3. Education: Last grade in school attended: 2
Can read? Yes
Can write? Yes
Is Home Health involved in your Care? No

5. Assistance required for Care
Toileting: Goes to bathroom alone, Independent
Medication: Taken best as: Liquid
Who else besides parents might be staying with child? N/A
Emotional Support: Has your family had any recent changes in your life? (moved, divorce, birth, death, new job, etc.): No

6. Abuse/Neglect/Exploitation Screen
Do you feel safe in your home? No (Originally Yes)
Are you afraid of anyone? No (Originally Yes)
Have you ever been physically, sexually, or emotionally abused? No
Within the past year, have you ever been hit, slapped, kicked, or otherwise physically hurt? No (REDACTED)
Have you ever been touched in a manner that makes you feel uncomfortable? No (REDACTED)
Evidence of neglect by self? No
Evidence of neglect by caretakers? No
Evidence of abuse by self or others? No

Comfort/Pain
Is the patient currently having pain or admitted a pain related diagnosis? Yes
RATING ON PAIN SCALE: 6
Location: Head
Duration: 2-4 Hrs
Chronic, dull
Relieved by Rest
Aggravated by Talking
Do you have any personal, cultural, spiritual, and/or ethnic beliefs that may affect the way your pain is treated? No

OOG there is another page on the blank version of this form (see sources), but Jay states that it isn't there. Given the nature of the information shown in the blank document, however, this is most likely unimportant.

Brief Operative Progress Note

Procedure: (Wound prep, incision, Findings, pathology, closure, etc.)A description may be present, but the entirety of the dedicated space is redacted, as is the remainder of the document. See PDF for more details on redacted info.